MEDICARE: DR. SHAYNA SMALLWOOD M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207Q00000X	Family Medicine Physician	ME146132	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	VR1ZK	OTHER	FL	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083140081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHAYNA SMALLWOOD M.D.

Provider Business Mailing Address
First Line	:	14311 METROPOLIS AVE STE 102
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-4442
Country	:	US
Telephone Number	:	239-768-0127
Fax Number	:	239-768-0671

Provider Business Practice Location Address
First Line	:	14311 METROPOLIS AVE STE 102
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-4442
Country	:	US
Telephone Number	:	239-768-0127
Fax Number	:	239-768-0671

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	03/17/2023

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